Free Motion for Approval of Disputed Charge - Idaho

______________________________
Name of party Submitting

______________________________
Address of party Submitting

______________________________
Phone of party Submitting

BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO

PROVIDER, v.

MOTION FOR APPROVAL OF DISPUTED CHARGE

PATIENT: PAYOR. DATE(S) OF SERVICE: DISPUTED AMOUNT: $

COMES NOW ____________________________, Movant, pursuant to Rule 19, Judicial Rules of Practice and Procedure (JRP), and moves the Industrial Commission of the State of Idaho for an order approving the fees for health care services set forth in Appendix "A" attached hereto, which fees have been objected to by the Employer and/or Surety named above to the extent indicated in Appendix "A". Payor has twenty-one (21) calendar days from the date it receives this motion to file its response. Rule 19, Judicial Rules of Practice and Procedure. Documents submitted in support of this motion are attached hereto and include the following: 1. 2. 3. 4. 5. DATED this _________ day of _______________________, 20_____. Appendix A: List of Charges in Dispute

_____________________________ Signature of Authorized Agent

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CERTIFICATE OF SERVICE I hereby certify that on the ______of ____________ , 20___, a true and correct copy of this Motion for Approval of Disputed Charges was served by upon each of the following, as noted: IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE, ID 83720-0041 US Mail Hand Delivery Fax ________ ________ ________

In State Payor's Address:

US Mail Hand Delivery Fax

________ ________ ________

Signature of Authorized Agent

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APPENDIX A MOTION FOR APPROVAL OF DISPUTED CHARGE Date of Service CPT Code / Item Description
(CPT Code is preferred)

Amount Billed

Amount Paid

Amount Objected to

TOTALS

(expand as necessary)

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APPENDIX B AFFIDAVIT OF USUAL AND CUSTOMARY

I, ___________________________, hereby attest and certify that: 1. I have personal knowledge of the information stated in this Affidavit, and it is true and accurate to the best of my information and belief. 2. The charges listed in Appendix A arose from medical services for an industrial injury under the Idaho Workers' Compensation law. 3. The charges listed in Appendix A are this Provider's most frequent charge(s) for the item(s) listed. 4. These charges are the same for all patients, whether industrially injured or not. 5. Attached hereto, or set out below, is: (check one)

_____ an accurate copy of our standard fee schedule for the items in Appendix A, (or) _____ bills for other patients, non-industrially injured, for the same service/treatment/charge.

DATED This ______ day of ___________________, 20___.

___________________________________ Authorized Agent

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